Undertake shared decision making with our complex care patients and their carers, to ensure that care delivered is holistic and focuses on what matters most to patients. Working as part of a team and autonomously to promote individualised patient-centred care to prevent hospitalisation, including end-of-life and complex cases with early intervention for frailty and vulnerability. Responding to medical problems presented by patients, including history taking, examination, investigation, diagnosis, treatment, and referral where appropriate. Produce and maintain accurate and detailed patient notes. Provide care to patients in their homes, as well as in care homes. To be a lead clinician for designated care homes and undertake weekly ward rounds. To support the wider practice delivery of care, including supporting urgent care on duty when appropriate. Management of palliative care, end-of-life processes, complex comorbidities, and chronic conditions. Working within the team to review and proactively contact those recently discharged from hospital, including alignment of medications and proactive onward care planning. Proactively identify and signpost support, for patients and their carers. Develop, maintain, and promote links with primary and secondary care. Attend MDT/ team meetings and lead as necessary. Implement proactive case management for all patients. Participate in clinical governance and audit programmes. Maintain clinical competence and performance through educational activity.